Glycerol and bacterial meningitis.

Scientific efforts aimed at improving the prognosis of patients affected by severe diseases deserve to be highlighted and thoroughly evaluated for potential impact. Despite modern intensive care management and the advent of potent, broad-spectrum antimicrobial agents, bacterial meningitis is still associated with unacceptably high rates of long-term morbidity and case fatality. During the past 20 years, comprehensive experimental and clinical studies have been performed to define the molecular pathophysiologic events involved in bacterial meningitis that are responsible for clinical manifestations and adverse outcomes. These studies have demonstrated that administration of dex-amethasone before the first effective par-enteral antibiotic dose reduced neurologic and/or audiologic sequelae in infants and children with Haemophilus influenzae meningitis and, possibly, in those infected with Streptococcus pneumoniae [1]. Recently , the benefit of corticosteroid therapy was confirmed in adults with pneu-mococcal meningitis [2]. Nevertheless, the favorable effects of treatment with dexamethasone are far from ideal, and in selected situations, they can be marginal or nonexistent. Children with delayed medical attention, profound malnutrition, HIV infection, or treatment with suboptimal antibiotics (based on current bacterial drug-resistance profiles) are less likely than others to respond to ad-junctive antiinflammatory therapy. These situations are commonly seen in poor regions of the world, as illustrated in a clinical trial conducted in Malawi [3]. Consequently, novel and accessible forms of adjuvant therapy are clearly needed for the unique challenges faced by countries with limited economic and technical resources. In this issue of the journal, Peltola et al. [4] explore the potential usefulness of glycerol in the context of a pediatric population with bacterial meningitis living in the underdeveloped public sectors of several Latin American nations. These authors should be congratulated for conducting the largest bacterial meningitis trial to assess the safety and efficacy of adjuvant strategies for treatment of this devastating disease. A talented group of investigators participated in a very complicated and difficult randomized, double-blinded study with 4 management arms comprising a glycerol group, a dexame-thasone group, a glycerol plus dexame-thasone group, and a placebo (carboxi-methylcellulose) group. In this study [4], 654 infants and children with bacterial meningitis caused predominantly by H. influenzae type b (Hib), pneumococci, and meningococci were enrolled. Glycerol was given to 159 patients, dexamethasone was given to 166, dexa-methasone and glycerol were given to 159, and placebo was given to 163. Compared with those patients who received placebo, patients receiving glycerol and patients receiving dexamethasone plus glycerol experienced fewer severe …